Unexpected instant death following successful coronary artery bypass graft surgery (and other clinical settings): atrial fibrillation, quinidine, procainamide, et cetera, and instant death.

Primum non nocere. Atrial fibrillation (AF) occurs commonly following coronary artery bypass graft surgery, although new onset atrial fibrillation in this setting is usually transient. When AF reverts or is converted to sinus rhythm it is unlikely to recur, whether or not the patient takes preventive medication. As no benefit (and sometimes increased risk) associated with reduced mortality or morbidity in this setting has been reported for antiarrhythmic agents, standard treatment should consist of observation or control of ventricular response with an appropriate agent until AF relapses to sinus rhythm. If an antiarrhythmic agent, especially a class I agent, is used because of persistent or recurrent AF in the early postoperative period, heart rhythm should be monitored as long as the class I agent is administered and treatment initiated if an undersirable rhythm develops. Atrial fibrillation in other clinical settings in patients with structural heart disease presents a more difficult management problem. Class I agents are reported to be associated with an increased risk of death, despite an efficacious effect of maintaining sinus rhythm. Amiodarone is reported to be well tolerated with respect to the cardiovascular system, but unacceptable noncardiac effects are reported. A safe amiodarone-like agent is greatly needed. Atrial fibrillation in patients with no structural heart disease is not discussed in this presentation.